ms julie horn and ms dianne jolley's presentation
TRANSCRIPT
Prepared by Julie Horn
Clinical Nurse Consultant Blood and Blood Product
Dianne Jolley
Quality and Safety Manager
Nepean Hospital
Identifying Risks and Implementing Safety Initiatives
In the Beginning
Two risks were identified
– Wastage of blood and blood products
– Safe administration of blood and blood products as per ANZSBT Guidelines & NSW Health Policy Directive
Evidence
2013 Transfusion Medicine dispensed 8,412 units of RBC’s at a cost of $2,903,317.68
2014 Transfusion Medicine dispensed 5,292 units of RBC’s at a cost of $1,826,480.88
Calculation of RBC at approximately $345.14 per unit
Wastage data
IIM’s- reviewing trends
Total IIMs recorded for 2013 was 39 incidents
Total IIMs recorded for 2014 was 44 incidents
Description of Incidents for 2013
0
1
2
3
4
5Wastage
Authority toIssue Form
BloodSample
Wrongblood/tube
Documentation
Description of Incidents for 2014
0
1
2
3
4
5
6Wastage
Authority toIssue Form
BloodSample
Wrongblood/tube
Documentation
Why the reduction in RBC usage? Why the number of IIMs increasing?
Better review process
Education
System Management
Improved Governance Structure
HCQC (Health Care Quality
Committee) LHD
District Blood Transfusion Committee
Standard 7 Working Group
Blood Transfusion Risk working
Group
Nepean Hospital Quality and Safety
Governance Committee
Nepean Hospital Patient Safety and
Quality Committee
Reflective questions from Standard 7 monitoring tool
How do we check that a broad history of blood products use is documented in the patients clinical record?
What review processes do we use to test that patient clinical records are accurate?
What information on blood and blood products (including the benefits, risks and alternatives) is available for clinicians to give to patients?
Right Blood Right Patient Checklist
Identified there were a number of gaps to meet Standard 7 for patient safety and engagement
Applying the WHO surgical “Time Out” to blood and blood product transfusion
To ensure patient were well informed of the risks verses benefits of the transfusion
Survey Questions for clinical staff
What is your nursing role?
Does your ward or clinical area have this checklist in stock? Y/N
Do you use the checklist when the patient is ordered a blood transfusion? Y/N
Is the checklist helpful? Y/N
Would you make any changes? Y/N
Staff feedback is positive Lithgow Hospital use it for every transfusion completing the
first section before collecting blood
Patient records audited for the presence and completeness of the Right Blood Right Patient Checklist. • 45% had the form present • 50% were complete
Where to from here
How do we ensure the patient clinical records have the transfusion process and patient care adequately documented?
References
Australia and New Zealand Society of Blood Transfusion Ltd (ANZSBT). Royal College of Nursing of Australia. 2011, Guidelines for the Administration of Blood Products, 2nd Edition, Australian and New Zealand Society of Blood Transfusion. Sydney, http://www.anzsbt.org.au/publications/documents/ANZSBT_Guidelines_Administration_Blood_Products_2ndEd_Dec_2011_Hyperlinks.pdf
Bloodsafe transfusion checklist http://www.transfusion.com.au/sites/default/files/TP-L3-402%20Nursing%20Admin%20Checklist%205.1.pdf
Google Imageshttps://www.google.com/search?site=&tbm=isch&source=hp&biw=1280&bih=625&q=critical+care+patient+blood+management&oq=critical+care+patient+blood+management&gs_l=img.12...1523.33568.0.35894.44.17.2.25.10.0.199.2875.0j15.15.0....0...1ac.1.64.img..25.19.2710.NTqNPhS9C9k#imgrc=_
South Australia Department of Health, 2012, Flippin’ Blood, Blood Safe Program, South Australia, 2nd edition.http://www.transfusion.com.au/resources/flippin-blood/index.html